- C. Assess the symptomatic quadrant last.
Rationale: The ideal position for abdominal examination is to sit or knee on the client’s right side with the hand and forearm in the same horizontal plane as the client’s abdomen. The nurse should start with superficial or light palpation from the area furthest from the point of maximal pain and move systematically through the four quadrants of the abdomen. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. If no pain is present, any starting point can be chosen (Mealie et al., 2022).
- A. Verbalizations of pain
Rationale: The best source of information about the client is the client themselves. Subjective data are information obtained directly from the client or symptoms the client feels, such as verbalizations of pain. Objective data are observable and may appear to contradict what the client says, but it does not mean that the subjective data is wrong. The nurse gathers objective nursing data from measurable sources including laboratory or diagnostic test results and vital signs. Other assessment procedures like ECG are also considered objective data (Faubion, 2023).
- B. Demonstrate the procedure and let the client perform a re-demonstration.
Rationale: Client education needs to be comprehensive and easily understood. Use return demonstration when administering care, involving the client from the first treatment procedure until discharge. This ensures that the client knows how to correctly perform the procedures and allows the nurse to correct any misconceptions and wrongdoings. An interpreter will ensure that the client understands the instructions on a language level, but it does not guarantee that the client will understand and retain the information in depth. Often, clients will nod “yes” or say that they comprehend what is taught even if they have not really heard or understood, therefore, asking the client frequently is not effective. Providing written instructions is good for retaining information, but it will not ensure that the client understands the rationale behind the procedure or how to perform the procedure accurately (Wolters Kluwer, 2017).
- A. The client’s cognitive abilities
Rationale: The adherence rate for medications in a study was significantly lower among males who were illiterate. It was also found that older adults who suffer from cognitive impairments have a lower adherence rate compared to their younger counterparts. A client’s cognitive ability affects medication administration because a higher cognitive capacity enables the client to pay more attention to their medications and their effects, thus increasing adherence. Clients with higher cognitive capabilities are generally more capable of receiving and handling knowledge. The client’s socioeconomic status, occupational hazards, and response to recovery do not affect medication administration as much as their cognitive abilities (Song et al., 2020).
- B. Restlessness
Rationale: An immediate, inadequate compensatory response to shock will result in dizziness, altered mental status, restlessness, or loss of consciousness. The central nervous system’s response to ischemia further stimulates the sympathetic nervous system after arterial pressure falls below 50 mm Hg. Subsequent compensatory mechanisms that work to restore blood volume to a normal level include the release of angiotensin and antidiuretic hormone, therefore decreasing the urine output and increasing blood pressure and heart rate (“Vital Signs Measurement,” 2018).
- C. Carotid
Rationale: The initial assessment is designed to help emergency medical responders to detect all immediate threats to life. If the client is not breathing, the pulse that should be checked is the carotid pulse. If the client is breathing, the nurse may check the radial pulse. If the carotid pulse is present but the radial pulse is absent, this may indicate shock (U.S. Department of Health and Human Services, 2022).
- D. Administering a BCG vaccine to a newborn.
Rationale: Primary prevention refers to the steps taken by an individual to prevent the onset of a disease. Secondary prevention focuses on reducing the impact of the disease by early diagnosis prior to any critical and permanent damage. Administering a BCG vaccine to a newborn is an example of primary prevention because its purpose is to prevent the development of childhood tuberculosis (Karunathilake & Ganegoda, 2018).
- B. Inspects the client’s abdomen first.
Rationale: The abdominal examination is performed with the client lying supine. It is important to begin with the general examination or inspection of the abdomen to identify the presence of any signs that may indicate specific disorders. Next, the nurse should auscultate the client’s abdomen using a stethoscope. Percussion is performed next by lightly percussing all four quadrants of the abdomen. Lastly, palpation is performed gently using the palmar aspect of the fingers and palpating clockwise. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make the assessment findings less accurate (Mehta, 2010).
- A. Nursing diagnosis
Rationale: A nursing diagnosis, according to the North American Nursing Diagnosis Association (NANDA) is defined as a clinical judgment about responses to actual or potential health problems on the part of the client, family, or community. Assessment is the first step and involves critical thinking skills and data collection, which includes subjective and objective data. Evaluation is the final step of the nursing process and is vital to a positive client outcome. Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care (Toney, 2022).
- C. Ineffective peripheral tissue perfusion related to venous congestion
Rationale: Deep vein thrombosis (DVT) is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. If left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening pulmonary embolism. Therefore ineffective peripheral tissue perfusion takes priority. DVT does not cause excess fluid volume, rather, it causes swelling of the peripheries or edema due to a disruption in the blood flow. The blood circulation is interrupted, not increased, as a result of venous stasis. Leg edema, instead of generalized edema, occurs due to a thrombus lodged in the iliac bifurcation, the pelvic veins, or the vena cava (Patel, 2019).
- D. Evaluation
Rationale: Whenever a healthcare provider or nurse intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending on the overall client condition. The plan of care may be adapted or revised based on new assessment data. The diagnosis, the interventions implemented, and the planning of the care plan must not be revised, otherwise, the nurse may need to restart the whole care plan again (Toney, 2022).
- B. Documentation of the medications given
Rationale: One crucial component of medical treatment is medication. Medication-related adverse events are among the most common healthcare-related adverse events. The medication process frequently involves several interfaces between different care professionals within or across hospital units, necessitating clear and transparent documents. In the course of treatment, nurses primarily administer medications and document the administration in the medication administration chart. Establishing desired outcomes, creating realistic goals, and developing the content outline are all part of the planning process (Hammer et al., 2021).
- C. Refer the client to a healthcare professional licensed for sex counseling.
Rationale: It is necessary for nurses to be able to answer the question given by a client, but only within the appropriate area competencies. Nurses may have specialist knowledge about the anatomy and physiology of the human body, however, sexology also includes issues from the border of psychology and the field of cultural products (Rozyk-Myrta et al., 2021). Arranging for a referral to a sex counselor is the best action that the nurse can take if the nurse does not have adequate training and credentials to conduct sex counseling for the client. Providing privacy for the client and their spouse to discuss their concerns may be done after they have an understanding of the effects of diabetes mellitus on their sexual relationship. Answering the client’s questions honestly is a nursing responsibility, but this should be within the scope of the nurse’s competence. Providing emotional support is a must for the nurse, but the client and the spouse should understand the implications of impotency first so that they could express their feelings appropriately and with insight.
- A. Risk for aspiration related to administration of general anesthesia
Rationale: Postoperative complication is a major contributor to the overall risk of abdominal surgery, and is associated with considerable morbidity and mortality. With a mortality rate of around 30%, aspiration pneumonia is the most precarious postoperative pulmonary complication. Surgical clients requiring general anesthesia and abdominal surgery have an increased risk of pulmonary aspiration and aspiration pneumonia (Struder et al., 2016). Acute pain can be managed with postoperative pain medications, and general anesthesia may take time to fade postoperatively, giving the client some relief from pain immediately after surgery. Fluids are replenished immediately after the client’s surgery, decreasing the risk of increased blood loss from the surgery. Ambulation is recommended at least 24 hours after the surgery, therefore impaired physical mobility is not the nurse’s priority.
- B. Assessing the client’s airway
Rationale: Airway, breathing, and circulation are foundational elements to assist the nurse in prioritization. Using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. Therefore, assessing the client’s airway takes priority among the other nursing actions. The assessment also takes place first when using the nursing process. Splinting the chest, providing pain relief, and calling the client’s relatives all fall under the implementation step. Additionally, interventions cannot be immediately provided without performing an effective, if fast-paced, assessment (Faubion, 2023).
- C. Preventing infection
Rationale: Leukopenia occurs when a client’s white blood cells (WBCs) are lower than normal. WBCs act as the immune system’s first line of defense. Without enough WBCs, the client is vulnerable to developing infections (Cleveland Clinic, 2022). The client’s hemoglobin and hematocrit levels are within the normal range, therefore it is unnecessary for the nurse to restore the fluid balance since fluid imbalance is not observed. Promoting rest is correct, however, it does not take precedence over the client’s risk of infection. Preventing injury is a nursing responsibility that the nurse should practice for every client. However, there is no immediate threat that can cause the client injury except for the increased risk of infection.
- D. Both are essential to use in nursing practice.
Rationale: Both critical thinking skills and the nursing process play a vital role when developing plans of care for client populations with multiple comorbidities. The nursing process is defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice recommendations, and nursing intuition. Critical thinking does not include a step-by-step procedure like the nursing process; critical thinking skills are essential to assessment. Critical thinking skills, such as those used during the assessment, is not necessarily client-centered. Data may come directly from the client or from the primary caregivers who may or may not be in direct relation to family members. Friends can also play a role in data collection (Toney, 2022).
- B. Diagnosis
Rationale: A nursing diagnosis is defined as a clinical judgment about responses to actual or potential health problems on the part of the client, family, or community. This is when the nurse analyzes the data gathered during assessment and uses these data to identify the client’s potential or actual problems. Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. Assessment is the first step and involves critical thinking skills and data collection. Evaluation is the final step of the nursing process and is vital to a positive client outcome (Toney, 2022).
- A. Evaluation
Rationale: Whenever the nurse intervenes or implements care, they must reassess or evaluate to ensure the desired outcomes have been met. This occurs during the evaluation phase. Reassessment may frequently be needed depending on the overall client’s condition. The planning stage is where goals and outcomes are formulated that directly impact client care based on evidence-based practice guidelines. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of client care. Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care (Toney, 2022).
- C. Both influence the nurse’s problem-solving and decision-making.
Rationale: Critical thinking is a habit of mind that helps explore ideas. It is both an attitude and a set of skills. A critical thinking attitude includes keeping an open mind and a willingness to have any idea questioned. Critical thinking skills include being able to define the idea in front clearly, determine the quality of evidence supporting that idea, and understand its implications or consequences. Both are employed by the nurse during care planning because they influence the problem-solving and decision-making processes (The University of New Mexico, 2018).
- D. The client reports being feverish; axillary temperature is at 98℉.
Rationale: Validating data is the process of confirming or verifying that the subjective and objective data collected are reliable and accurate. Data requiring validation includes discrepancies or gaps between the subjective and objective data (Quizlet, 2021). The client reported feeling feverish but the axillary temperature is within the normal range, therefore, this data needs to be validated. All the other options have supporting details that confirm the accuracy of the results shown.
- B. Maslow’s Hierarchy of Needs; C. Gordon’s Functional Health Patterns
Rationale: Maslow’s Hierarchy of Needs states that actions are motivated by certain physiological and psychological needs that progress from basic to complex. To achieve the ultimate goal, a number of more basic needs must be met. This includes the need for food, safety, love, and self-esteem (Cherry, 2022). Meanwhile, information obtained when assessing functional health provides the nurse with a holistic view of a client’s human response to illness and life conditions. It is helpful to use an assessment framework, such as Gordon’s Functional Health Patterns, to organize interview questions according to evidence-based patterns of human responses. Using this framework provides the client and their family members an opportunity to identify health-related concerns to the nurse that may require further in-depth assessment (Wisconsin Technical College System, 2021). A head-to-toe assessment focuses on identifying physiological needs or disease conditions. A body system model is basically a representation of all the body systems. The Adaptation Model of Nursing is a nursing theory developed by Sister Callista Roy to explain the provision of nursing science.
- C. Inspection, palpation, percussion, auscultation
Rationale: Observation, or inspection, is the most important physical assessment technique for practitioners to master. A specific observation may alert the examiner to assess a particular system more thoroughly. Palpation is a technique in which the examiner uses the sense of touch to assess both superficial and deeper body characteristics. Percussion refers to tapping or striking a part of the body to put underlying tissue into motion. This movement produces audible sounds and palpable vibrations, which are then assessed for the quality and duration of their tone and notes. Auscultation is the technique of listening to sounds produced by the body (Honeyfield & Tappero, 2018). This sequence is performed systemically so that no disturbances can occur to the body systems being assessed, which can later produce inaccurate assessment findings.
- A. Show how the equipment works first before using it.
Rationale: Demonstrating how the equipment for physical examination functions (e.g. penlight, reflex hammer) will help the school-aged client understand the procedures and increase the client’s cooperation. Asking the parents to leave may increase the client’s anxiety. Allowing the client to help during the procedure may produce inaccurate findings. Performing invasive procedures is best for all age groups; therefore, this action is not specific to the school-aged client.
- D. Separating the skin folds with clean towels
Rationale: Skin surfaces in deep folds can be kept separated with cotton or linen cloth; however, they should not be tight, occlusive, or chafing to the client. Formulations combining protective agents, antimicrobials, and topical steroids may be helpful, including Triple Paste, which contains petrolatum, zinc oxide paste, and aluminum acetate. Petrolatum-based barrier products are greasy, which can contribute to increasing the moisture between skinfolds, making it conducive for bacteria to grow. Keeping the folds cool and dry eliminates friction, heat, and maceration (Vakharia & James, 2020).
- A. Document it as a late entry in the client’s chart.
Rationale: If there is a delay in adding notes or the nurse forgot to document a nursing action, the note can be documented as a late entry so that there is no confusion over what happened and when. An occurrence or incident report provides a factual description of an adverse event or near miss that supports learning, safety, and improved care quality (Brigham, 2019). Never let another nurse chart a procedure they did not perform, because the one who documented and signed the entry is accountable for whatever they had written. A client’s chart is a legal document, and inserting it on earlier notes can make the document unreliable and inadmissible. This will also confuse the medical professionals reading the client’s chart about when the action was performed.
- B. Perineal skin irritation
Rationale: 24 to 45% of women report some degree of urinary incontinence. The perineal skin, when exposed to urine for long periods of time, may become irritated. A decrease in fluid intake may help decrease episodes of incontinence, especially during nighttime. A history of diuretic use is usually linked to urinary incontinence because it promotes diuresis. An increase in dietary salt intake may result in the reabsorption of water, which in turn decreases diuresis (Tran & Puckett, 2022).
- B. Assess the penis for circulation after 30 minutes.
Rationale: Inspect the penis with the condom catheter in place within 15 to 30 minutes of applying it. Assess the penis for any swelling or discoloration, and ask the client for any discomfort. This ensures that any complication can be prevented within the earliest possible time (Mosby’s Nursing Video Skills, 2018). The condom catheter should be changed every day or every 24 hours, or when the urine collection bag is full. The collecting tube should be attached securely to the leg or below the knee with enough slack so it does not pull on the catheter. The condom catheter must be the right fit and size for the client so that it is comfortable and secure. It should not be too tight, as this can impede circulation (Cleveland Clinic, 2022).
- A. Urge urinary incontinence
Rationale: Urge incontinence is the involuntary leakage of urine that may be preceded or accompanied by a sense of urgency due to detrusor overactivity. The contractions may be caused by bladder irritation or loss of neurologic control. Stress urinary incontinence is the involuntary leakage of urine that occurs with increases in intraabdominal pressure (with exertion, coughing, sneezing) due to the urethral sphincter and/or pelvic floor weakness. Functional urinary incontinence is the involuntary leakage of urine due to environmental or physical barriers to toileting. Overflow urinary incontinence is the involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction (Tran & Puckett, 2022).
- C. The client performs pelvic muscle exercises.
Rationale: Pelvic muscle exercises like Kegels can strengthen the muscles involved with urination. Contracting the pelvic muscles when the urge to urinate occurs can help ease the urge to void. A key part of bladder training is aiming to go to the bathroom at regular intervals throughout the day, not when there is an urge to void. This helps the bladder adjust to a certain frequency. Juices from citrus fruits like orange and grapefruit may irritate the bladder, therefore consumption of these beverages should be reduced or limited. Diapers are not necessary during the bladder training period. The use of these products will not help the client’s bladder control at all (Coward, 2022).
- Brigham, G. (2019, June 4). Incident (occurrence) reporting: a cornerstone for safety and quality…. Washington State Nurses Association. https://www.wsna.org/news/2019/incident-occurrence-reporting-a-cornerstone-for-safety-and-quality-improvement
- Cherry, K. (2022, August 14). Maslow’s Hierarchy of Needs Theory. Verywell Mind. Retrieved March 4, 2023, from https://www.verywellmind.com/what-is-maslows-hierarchy-of-needs-4136760#toc-progressing-through-the-pyramid-of-needs
- Cleveland Clinic. (2022). Home. YouTube. Retrieved March 4, 2023, from http://ic.org/health/treatments/22475-condom-catheter-for-incontinence
- Cleveland Clinic. (2022, October 27). Low White Blood Cell Count (Leukopenia): Causes, Symptoms & Treatment. Cleveland Clinic. Retrieved March 4, 2023, from https://my.clevelandclinic.org/health/symptoms/17706-low-white-blood-cell-count
- Coward, M. (2022, April 21). Overactive Bladder Training: Benefits, How-To, and FAQs. Healthline. Retrieved March 4, 2023, from https://www.healthline.com/health/urinary-incontinence/overactive-bladder-bladder-training#fa-qs
- Faubion, D. (2023). Subjective VS. Objective Nursing Data: What’s The Difference. Nursingprocess.org. Retrieved February 26, 2023, from https://www.nursingprocess.org/subjective-vs-objective-nursing-data.html
- Finkelstein, J. (2020). 2.3 Tools for Prioritizing – Nursing Management and Professional Concepts. WI Technical Colleges Open Press. Retrieved March 4, 2023, from https://wtcs.pressbooks.pub/nursingmpc/chapter/2-3-tools-for-prioritizing/
- Hammer, A., Wagner, A., Rieger, M. A., & Manser, T. (2021, December 15). Drug Utilization Review – StatPearls. NCBI. Retrieved March 4, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK441869/
- Honeyfield, M. E., & Tappero, E. P. (2018). Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. Springer Publishing Company.
- Karunathilake, S. P., & Ganegoda, G. U. (2018). Secondary Prevention of Cardiovascular Diseases and Application of Technology for Early Diagnosis. BioMed Research International, 2018. https://www.hindawi.com/journals/bmri/2018/5767864/
- Mealie, C. A., Ali, R., & Manthey, D. E. (2022, October 10). Abdominal Exam – StatPearls. NCBI. Retrieved February 26, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK459220/
- Mehta, M. (2010). Assessing the abdomen. Nursing Critical Care, 5(1). https://journals.lww.com/nursingcriticalcare/fulltext/2010/01000/assessing_the_abdomen.11.aspx
- Mosby’s Nursing Video Skills. (2018). Mosby’s Nursing Video Skills. Mosby’s Nursing Video Skills. Retrieved March 4, 2023, from https://www.ndsu.edu/pubweb/bismarcknursing/basic/skill/E003.html
- Patel, K. (2019, June 5). Deep Venous Thrombosis (DVT): Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved March 3, 2023, from https://emedicine.medscape.com/article/1911303-overview#a1
- Quizlet. (2021). Health Assessment (Validation and Documentation of Data). Quizlet. Retrieved March 4, 2023, from https://quizlet.com/583731178/health-assessment-validation-and-documentation-of-data-flash-cards/
- Rozyk-Myrta, A., Brodziak, A., & Kolat, E. (2021). An Attempt to Assess Nurses’ Competence in Field of Sexual Counseling and Education. Neuro Research, 3(2). https://doi.org/10.35702/nrj.10009
- Song, Y.-Q., Zhang, W.-R., Zhang, S.-X., Wang, T.-H., Jiang, Z., Meng, C.-F., Zhang, T.-Z., Xin, Q.-Z., Cao, K.-J., Zhang, Y., & Sun, Y. (2020). Factors Influencing Administration, Recognition, and Compliance of Medicine among Community Residents from Jilin Province, China: A Questionnaire Study. Hindawi. Retrieved February 26, 2023, from https://www.hindawi.com/journals/bmri/2020/8730212/
- Struder, P., Räber, G., Ott, D., Cardinas, D., & Schnüriger, B. (2016, March). Risk factors for fatal outcome in surgical patients with postoperative aspiration pneumonia. International Journal of Surgery, 27. https://www.sciencedirect.com/science/article/pii/S1743919116000522?via%3Dihub
- Toney, T. J. (2022, April 14). Nursing Process – StatPearls. NCBI. Retrieved February 26, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499937/
- Toney, T. J. (2022, April 14). Nursing Process – StatPearls. NCBI. Retrieved March 3, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499937/
- Tran, L. N., & Puckett, Y. (2022, August 8). Urinary Incontinence – StatPearls. NCBI. Retrieved March 4, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559095/
- The University of New Mexico. (2018). 5 ESSENTIAL CRITICAL THINKING SKILLS :: THE UNM 5 | The University of New Mexico. THE UNM 5. Retrieved March 4, 2023, from https://unm5.unm.edu/5-essential-CRITICAL-THINKING-skills.html
- U.S. Department of Health and Human Services. (2022, November 16). Primary, Secondary Survey. CHEMM. Retrieved February 26, 2023, from https://chemm.hhs.gov/appendix8.htm
- Vakharia, P., & James, W. D. (2020, November 13). Intertrigo Treatment & Management: Approach Considerations, Medical Care, Complications. Medscape Reference. Retrieved March 4, 2023, from https://emedicine.medscape.com/article/1087691-treatment#d9
- Vital Signs Measurement. (2018). In J. R. Roberts (Ed.), Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Elsevier.
- Wisconsin Technical College System. (2021). 2.8 Functional Health and Activities of Daily Living – Nursing Skills. WI Technical Colleges Open Press. Retrieved March 4, 2023, from https://wtcs.pressbooks.pub/nursingskills/chapter/2-8-functional-health-and-activities-of-daily-living/
- Wolters Kluwer. (2017). 5 Strategies for Patient Education as a Nurse. Wolters Kluwer. Retrieved February 26, 2023, from https://www.wolterskluwer.com/en/expert-insights/5-strategies-for-providing-effective-patient-education